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Hemorrhoids Grading & Size Chart

Know the grades of hemorrhoids using an easy-to-read size chart. Learn symptoms, severity, and treatment options by grade.

Know the grades of hemorrhoids using an easy-to-read size chart. Learn symptoms, severity, ... and treatment options by grade. Read More

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What are Hemorrhoids?

Hemorrhoids (also called piles) are swollen blood vessels in the rectal or anal area, often caused by straining, constipation, or prolonged sitting. They can be internal or external, and vary in size and severity.

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Classification of hemorrhoids

Internal Hemorrhoids

Located inside the rectum
Painless bleeding
Classified by grades (I to IV)

External Hemorrhoids

Located under the skin around the anus
Painful, may form clots (thrombosed)
Not graded by size, but by symptoms

Internal Hemorrhoids Grading and Size Chart

Grade	Size	Prolapse Status	Symptoms	Common Treatment
Grade I	Small (≤0.5 cm)	No prolapse	Bleeding, discomfort	Diet changes, creams
Grade II	Moderate (0.5–1 cm)	Prolapse with straining, retracts on its own	Bleeding, itching	Rubber band ligation, sclerotherapy
Grade III	Large (1–2 cm)	Prolapse requires manual reduction	Pain, bleeding, swelling	Stapler surgery, banding
Grade IV	Very Large (>2 cm)	Permanent prolapse, cannot be pushed back	Severe pain, leakage, thrombosis	Hemorrhoidectomy, laser surgery

Key Differences in Internal Hemorrhoid Grades

Grade I: Only visible through endoscopy, usually painless.
Grade II: May protrude while passing stool but go back on their own.
Grade III: Needs manual push-back after prolapse.

Grade IV: Always outside, risk of clot formation (thrombosis).
Hemorrhoid Size Reference Table (Approx.)

Size in cm	Appearance	Grade Indicator
0.2 – 0.5 cm	Mild swelling, internal only	Grade I
0.5 – 1 cm	Mild prolapse with straining	Grade II
1 – 2 cm	Bulging, needs manual push	Grade III
2 – 3+ cm	Always prolapsed, visible	Grade IV

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Symptoms of Hemorrhoids by Grade

Degree of Piles	Symptoms
I	Light bleeding, discomfort, itching
II	Bright red blood, mild pain, mucous discharge
III	Swelling, persistent bleeding, sensation of incomplete evacuation
IV	Severe pain, difficulty sitting, fecal leakage, thrombosis

External hemorrhoids classification

Features	Thrombosed	Non-thrombosed
Color	Blue, purple, black	Similar to the color of your skin
Pain	Yes, usually very painful	Soft to touch
Blood clot	Forms in the vein	Do not have a blood clot

When to Seek Medical Help?

You should consult a proctologist if:

Bleeding lasts >1 week
Pain worsens while sitting or walking
Hemorrhoids protrude and don’t retract
There’s a noticeable lump or clot

Diagnostic Methods

Digital Rectal Examination (DRE)
Anoscopy
Proctoscopy
Colonoscopy (if bleeding origin is unclear)

Treatment Options Based on Grading

Grade I & II

High-fiber diet
Sitz bath
Topical creams (lidocaine, hydrocortisone)
OTC medications (Daflon)

Non-surgical methods

Rubber band ligation
Infrared coagulation (IRC)
Sclerotherapy

Grade III

May require:

Stapled Hemorrhoidopexy
Doppler-guided hemorrhoidal artery ligation (DG-HAL)
Minimally invasive laser surgery

Grade IV

Surgical options:

Conventional Hemorrhoidectomy (Milligan-Morgan)
Laser Hemorrhoidoplasty
Stapled Hemorrhoidopexy

When is Surgery Needed?

Surgery is recommended when:

Hemorrhoids are Grade III or IV
Recurrent bleeding despite treatment
Severe thrombosis (clot)
Non-surgical methods fail

Summary

Feature	Grade I	Grade II	Grade III	Grade IV
Visible Outside?	❌	❌ (temporarily)	✅ (manual push required)	✅ (permanently)
Bleeding	Mild	Moderate	Heavy	Severe
Pain Level	Low	Mild	Moderate	Severe
Treatment Type	Conservative	Non-surgical	Semi-surgical	Surgical

FAQs

What is the most severe grade of hemorrhoids?

Grade IV is the most severe and usually requires surgical removal due to permanent prolapse.

Can Grade I hemorrhoids go away on their own?

Yes. With lifestyle changes and topical medications, Grade I hemorrhoids often resolve without advanced treatment.

Is size the only indicator of hemorrhoid grade?

No. Grading is based on prolapse behavior, not just physical size.

Can hemorrhoid size increase with time?

Yes. If untreated, hemorrhoids may worsen from Grade I to IV, increasing in size and symptoms.

Are external hemorrhoids graded the same way?

No. External hemorrhoids are not graded but assessed based on pain, size, and clot formation.

Medically Reviewed By

Dr. Shashank Subhashchandra Shah

36 Years Experience Overall

Last Updated : December 12, 2025

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